Theatre improvisation training to promote social cognition: A novel recovery-oriented intervention for youths at clinical risk for psychosis.

AIM: Few interventions address social cognition or functioning in individuals at clinical risk (CR) for psychosis. Theatre Improvisation Training to Promote Social Cognition (TIPS) is a manualized intervention based on drama therapy. We aim to describe TIPS, evaluate feasibility and acceptability, and present a preliminary investigation of outcomes in a quasi-experimental design. METHODS: Thirty-six CR participants (15-25 years) were ascertained from the Philadelphia Neurodevelopmental Cohort. Twenty-six completed the TIPS protocol: 18 weekly 2-hour group sessions led by a theatre director and actor-assistant. Participants engaged in collaborative acting and improvisation exercises. Baseline and follow-up assessments included the Clinical Assessment Interview for Negative Symptoms (CAINS), Structured Interview for Prodromal Syndromes, Global Assessment of Functioning (GAF) and Penn Computerized Neurocognitive Battery (CNB), which includes social cognitive tests. Acceptability was assessed using focus groups. Preliminary outcomes were compared to CR controls who were not enrolled in the study but completed follow-up assessments using the same methods. RESULTS: There were no significant differences in baseline demographics, psychosis symptoms, or cognition between those who did and did not complete the protocol. Overall, TIPS was considered feasible and acceptable among CR. Preliminary outcomes suggest that TIPS may be effective in improving positive and negative psychosis-spectrum symptoms and GAF, but not performance on facial emotion processing. CONCLUSIONS: TIPS is a promising and acceptable intervention that may improve symptoms and functioning in CR while providing a framework for participants to develop more empowered and confident ways of relating to others. Larger randomized controlled trials investigating TIPS efficacy are warranted.

In and out of schizophrenia: Activation and deactivation of the negative and positive schemas.

Theorists, clinicians, and investigators have attempted to find a common source for the negative and positive symptoms of schizophrenia. We propose that a unified theory, based on a common cognitive structure not only has explanatory value, but can serve as a framework for a psychotherapeutic intervention. Specifically, we propose that the cognitive triad - the negative view of the self, others, and the future - is the source of the content for the negative and positive symptoms. We report literature supporting the relationship between each facet of the negative triad and each of the key symptoms: expressive negative symptoms, delusions, and verbal hallucinations. We conclude that the literature supports the validity of the cognitive model of negative and positive symptoms. The cognitive model furthers the understanding of the positive and negative symptoms of schizophrenia, and we describe how this provides a framework for a psychotherapeutic intervention.

Treatment Implications of Situational Variability in Cognitive and Negative Symptoms of Schizophrenia.

Cognitive impairments and negative symptoms in schizophrenia are associated with poorer outcomes and are typically resistant to pharmacological interventions. However, these features can vary dramatically in their level of expression, and they can improve as a function of external context (by providing performance-contingent incentives and a more stimulating environment) and internal context (by challenging defeatist performance beliefs and by reducing stress and improving physical health). This Open Forum briefly reviews some of this evidence for the situational variability of cognitive impairments and negative symptoms in schizophrenia and highlights psychosocial treatments that capitalize on this variability. The authors' goals are to stimulate development and implementation of interventions and to show practitioners how they can achieve more positive outcomes in their clinical work with what is often seen as a hard-to-treat population.

Beck Self-Esteem Scale-Short Form: Development and psychometric evaluation of a scale for the assessment of self-concept in schizophrenia.

A requisite step for testing cognitive theories regarding the role of self-concept in schizophrenia is the development of measures that follow a cognitive conceptualization and better capture the multifaceted nature of this construct. The purpose of this study was to examine the psychometric properties a new self-concept measure, the Beck Self-Esteem Scale-Short Form (BSES-SF), based on a sample of 204 individuals with schizophrenia or schizoaffective disorder. We evaluated the BSES-SF's dimensionality, internal consistency reliability, and construct and divergent validity using confirmatory factor analysis, Cronbach's alpha, Pearson correlations, independent samples t-tests, and one-way analysis of variance. Findings indicate that the 10-item BSES-SF is a reliable and valid measure of self-concept that is appropriate for a broad group of individuals with schizophrenia spectrum disorders. Following cognitive theory, the scale demonstrated significant relationships with delusion severity, motivation, and depression, further signifying its utility for research and practice efforts that are designed to address psychopathology in schizophrenia.

Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals With Schizophrenia.

OBJECTIVE: The study examined six-month follow-up results and the impact of length of illness on treatment outcomes of recovery-oriented cognitive therapy (CT-R). METHODS: Sixty outpatients (mean age 38.4 years, 33% female, 65% African American) with schizophrenia or schizoaffective disorder and elevated negative symptoms were randomly assigned to CT-R or standard treatment. Assessments were conducted at baseline, midtreatment (six and 12 months), end of treatment (18 months), and follow-up (24 months, N=46 after attrition) by assessors blind to treatment condition. Global functioning, measured with the Global Assessment Scale, was the primary outcome. Secondary outcomes were negative symptoms (avolition-apathy score on the Scale for the Assessment of Negative Symptoms) and positive symptoms (total score on the Scale for the Assessment of Positive Symptoms). Length of illness indexed chronicity (less chronic, one to 12 years; more chronic, 13 to 40 years). RESULTS: Intent-to-treat analyses (hierarchal linear modeling) at follow-up indicated significant benefits for individuals assigned to CT-R compared with standard treatment: higher global functioning scores (between-group Cohen's d=.53), lower scores for negative symptoms (d=-.66), and lower scores for positive symptoms (d=-1.36). Length of illness moderated treatment effects on global functioning, such that those with a less chronic illness began to show improvements earlier (at the trend level by six months and reaching significance by the end of treatment), whereas the group with a more chronic illness did not show significant improvements until later (at follow-up). CONCLUSIONS: CT-R produced durable effects that were present even among individuals with the most chronic illness.

Successfully breaking a 20-year cycle of hospitalizations with recovery-oriented cognitive therapy for schizophrenia.

Individuals with severe and persistent schizophrenia can present challenges (e.g., difficulties sustaining motivation and conducting information processing tasks) to the implementation of recovery-oriented care. We present a successful application of recovery-oriented cognitive therapy (CT-R), a fusion of the spirit and principles of the recovery movement with the evidence base and know-how of cognitive therapy, that helped an individual with schizophrenia move along her recovery path by overcoming specific obstacles, including a 20-year cycle of hospitalizations (five per year), daily phone calls to local authorities, threatening and berating "voices," the belief that she would be killed at any moment, and social isolation. Building on strengths, treatment included collaboratively identifying meaningful personal goals that were broken down into successfully accomplishable tasks (e.g., making coffee) that disconfirmed negative beliefs and replaced the phone calling. At the end of treatment and at a 6-month follow-up, the phone calls had ceased, psychosocial functioning and neurocognitive performance had increased, and avolition and positive symptoms had decreased. She was not hospitalized once in 24 months. Results suggest that individuals with schizophrenia have untapped potential for recovery that can be mobilized through individualized, goal-focused psychosocial interventions.

Effects of a recovery-oriented cognitive therapy training program on inpatient staff attitudes and incidents of seclusion and restraint.

We investigated the feasibility of implementing a recovery-oriented cognitive therapy (CT-R) milieu training program in an urban acute psychiatric inpatient unit. Over a 1-month period, 29 staff members learned short-term CT-R strategies and techniques in an 8-h workshop. Trainees' perceptions of CT-R, beliefs about the therapeutic milieu, and attitudes about working with individuals with psychosis were evaluated both before the workshop and 6 months after the workshop had been completed. Incidents of seclusion and restraint on the unit were also tallied prior to and after the training. Results indicate that staff perceptions of CT-R and their beliefs about the therapeutic environment significantly improved, whereas staff attitudes towards individuals with psychosis remained the same. Incidents of seclusion and restraint also decreased after the training. These findings provide evidence that CT-R training is feasible and can improve the therapeutic milieu of an acute psychiatric inpatient unit.

Dysfunctional attitudes and expectancies in deficit syndrome schizophrenia.

The deficit syndrome was proposed over 20 years ago as a separate negative symptom syndrome within schizophrenia with a distinct neurobiological pathophysiology and etiology. Recent research, however, has indicated that psychological factors such as negative attitudes and expectancies are significantly associated with the broad spectrum of negative symptoms. Specifically, defeatist beliefs regarding performance mediate between neurocognitive impairment and both negative symptoms and functional outcome. Additionally, asocial beliefs predict asocial behavior and negative expectancies regarding future pleasure are associated with negative symptoms. The present study explored whether these dysfunctional beliefs and negative expectancies might also be a feature of the deficit syndrome. Based on a validated proxy method, 22 deficit and 72 nondeficit patients (from a pool of 139 negative symptom patients) were identified and received a battery of symptom, neurocognitive, and psychological measures. The deficit group scored significantly worse on measures of negative symptoms, insight, emotion recognition, defeatist attitudes, and asocial beliefs but better on measures of depression, anxiety, and distress than the nondeficit group. Moreover, the deficit group showed a trend for higher scores on self-esteem. Based on these findings, we propose a more comprehensive formulation of deficit schizophrenia, characterized by neurobiological factors and a cluster of psychological attributes that lead to withdrawal and protect the self-esteem. Although the patients have apparently opted-out of participation in normal activities, we suggest that a psychological intervention that targets these negative attitudes might improve their functioning and quality of life.

Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia.

CONTEXT: Low-functioning patients with chronic schizophrenia have high direct treatment costs and indirect costs incurred due to lost employment and productivity and have a low quality of life; antipsychotic medications and psychosocial interventions have shown limited efficacy to promote improved functional outcomes. OBJECTIVE: To determine the efficacy of an 18-month recovery-oriented cognitive therapy program to improve psychosocial functioning and negative symptoms (avolition-apathy, anhedonia-asociality) in low-functioning patients with schizophrenia. Design, Setting, and PARTICIPANTS: A single-center, 18-month, randomized, single-blind, parallel group trial enrolled 60 low-functioning, neurocognitively impaired patients with schizophrenia (mean age, 38.4 years; 33.3% female; 65.0% African American). INTERVENTIONS: Cognitive therapy plus standard treatment vs standard treatment alone. MAIN OUTCOME MEASURES: The primary outcome measure was the Global Assessment Scale score at 18 months after randomization. The secondary outcomes were scores on the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms at 18 months after randomization. RESULTS: Patients treated with cognitive therapy showed a clinically significant mean improvement in global functioning from baseline to 18 months that was greater than the improvement seen with standard treatment (within-group Cohen d, 1.36 vs 0.06, respectively; adjusted mean [SE], 58.3 [3.30] vs 47.9 [3.60], respectively; P = .03; between-group d = 0.56). Patients receiving cognitive therapy as compared with those receiving standard treatment also showed a greater mean reduction in avolition-apathy (adjusted mean [SE], 1.66 [0.31] vs 2.81 [0.34], respectively; P = .01; between-group d = -0.66) and positive symptoms (hallucinations, delusions, disorganization) (adjusted mean [SE], 9.4 [3.3] vs 18.2 [3.8], respectively; P = .04; between-group d = -0.46) at 18 months. Age was controlled in the analyses, and there were no meaningful group differences in baseline antipsychotic medications (class or dosage) or in medication changes during the course of the trial. CONCLUSION: Cognitive therapy can be successful in promoting clinically meaningful improvements in functional outcome, motivation, and positive symptoms in low-functioning patients with significant cognitive impairment. Trial Registration  clinicaltrials.gov Identifier: NCT00350883.

Assessment of cognitive insight: a qualitative review.

The concept of cognitive insight was introduced in 2004 to describe the capacity of patients with psychosis to distance themselves from their psychotic experiences, reflect on them, and respond to corrective feedback. The Beck Cognitive Insight Scale (BCIS) was developed to evaluate these aspects of cognitive flexibility and to complement scales that describe the lack of awareness of mental illness and its characteristics. The BCIS has generated a moderate research literature, which is the subject of the current review. Several independent groups have demonstrated that the BCIS is reliable, demonstrates convergent and construct validity, and distinguishes patients with psychosis from healthy controls and patients without psychosis. While the majority of the studies have focused on the relationship of the BCIS to delusions, several have examined its relationship to negative symptoms, depression, anxiety, and functional outcome. Cognitive insight has predicted positive gains in psychotherapy of psychosis, and improvement in cognitive insight has been correlated with improvement in delusional beliefs. Finally, preliminary findings relate neurocognition, metacognition, and social cognition, as well as reduced hippocampal volume to cognitive insight. A heuristic framework is presented to guide future research.

Asocial beliefs as predictors of asocial behavior in schizophrenia.

Poor social and vocational outcomes have long been observed in schizophrenia, and therapeutic outcomes have been modest. Most studies have identified neurocognition and emotion perception as important contributors to social functioning. Recent research has suggested that personal beliefs, attitudes, and expectancies contribute to negative symptoms. However, the impact of specific beliefs and expectancies on social withdrawal in schizophrenia has not been examined. The present study explored: 1. whether asocial beliefs made a significant contribution to social functioning after accounting for neurocognitive performance and emotion perception; and, 2. whether asocial beliefs predicted asocial behavior in a longitudinal design. 123 outpatients diagnosed with schizophrenia or schizoaffective disorder completed tests of neurocognitive performance, emotion perception, asocial beliefs, symptomatology, and functional outcome. A subset of 13 outpatients was retested one year after the initial assessment. Hierarchical regression indicated that asocial beliefs accounted for 18% of the variability in social functioning. Depression and negative symptoms explained another 9% of the dispersion. Contrary to expectations, neurocognition and emotion perception accounted for less than 1% of the variance. In the longitudinal study, baseline asocial beliefs predicted asocial behavior one year later. Asocial beliefs predict poor social functioning in schizophrenia, and may be modifiable by psychological interventions.

Training and Consultation in Evidence-Based Psychosocial Treatments in Public Mental Health Settings: The ACCESS Model.

We present a model of training in evidence-based psychosocial treatments (EBTs). The ACCESS (assess and adapt, convey basics, consult, evaluate, study outcomes, sustain) model integrates principles and findings from adult education and training literatures, research, and practical suggestions based on a community-based clinician training program. Descriptions of the steps are provided as a means of guiding implementation efforts and facilitating training partnerships between public mental health agencies and practitioners of EBTs.

Negative performance beliefs and negative symptoms in individuals at ultra-high risk of psychosis: a preliminary study.

BACKGROUND: Negative beliefs regarding task performance have been shown to correlate with negative symptom severity in patients with chronic schizophrenia. We conducted a pilot study to determine whether the association also exists in individuals at ultra-high risk of psychosis. SAMPLING AND METHODS: The sample consisted of 38 individuals at ultra-high risk of psychosis and 51 controls. All participants completed the Abbreviated Dysfunctional Attitudes Scale; the ultra-high-risk participants were assessed with the Positive and Negative Syndrome Scale. RESULTS: High-risk participants endorsed negative performance beliefs to a greater extent than controls and these beliefs were associated with greater negative symptom severity, independent of depression and positive symptoms. CONCLUSIONS: The findings are consistent with previous results in chronic patients, and suggest that negative performance beliefs may be a promising psychological factor worthy of further attention in individuals at high risk of psychosis. Longitudinal research with more comprehensive assessment is needed to elucidate the potential role of negative performance beliefs in this population.

Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia.

Poor social and vocational outcomes have long been observed in schizophrenia. Two of the most consistent predictors are negative symptoms and cognitive impairment. We investigate the hypothesis that cognitive content--defeatist beliefs regarding performance--provides a link between cognitive impairment, negative symptoms, and poor functioning in schizophrenia. A total of 77 individuals (55 patients diagnosed with schizophrenia or schizoaffective disorder and 22 healthy controls) participated in a cross-sectional study of psychopathology. Tests of memory, abstraction, attention, and processing speed, as well as current psychopathology, functioning, and endorsement of defeatist beliefs, were employed. Greater neurocognitive impairment was associated with elevated defeatist belief endorsement, higher negative symptom levels, and worse social and vocational functioning. Notably, statistical modeling indicated that defeatist belief endorsements were mediators in the relationship between cognitive impairment and both negative symptoms and functioning. These effects were independent of depression and positive symptom levels. The results add to the emerging biopsychosocial understanding of negative symptoms and introduce defeatist beliefs as a new psychotherapeutic target.